Quality Healthcare Starts with Primary Care
by Christina Onolaja, MHA
Over the past 40 years, we've seen a large shift in primary care and the United States healthcare system. Unfortunately, the changes have resulted in a very broken system, and we now more than ever see the need to correct the flaws.
Historically, primary care was physician-driven, and the doctor had a paper appointment book where they would write a patient name in a slot. It was based on the provider's availability and when they wanted to schedule that patient.
Patients would come in for their visit, see their provider, and chat about their health. The physician sat there and looked at the patient, talked to them, asked them questions about their history, observed their general appearance, conducted a physical exam, and discussed their symptoms. The appointment was a dialogue. It wasn't a visit focused on checking boxes in a computer system. It wasn't spent with a doctor's head down typing on a keyboard. Instead, it was filled with a genuine connection - eye contact and listening.
As healthcare has evolved, that type of visit has become more and more challenging.
In the 1990s, a significant shift to electronic documentation resulted in a need to share, track, and protect patient data. The Health Insurance Portability and Accountability Act (HIPAA) was signed into law in 1996 requiring healthcare organizations to protect patient health record information. Subsequently, the Health Information Technology for Economic and Clinical Health (HITECH) Act, part of the American Recovery and Reinvestment Act of 2009, further expanded the HIPAA privacy law to require additional electronic protections of patient data. Further, the Healthcare Effectiveness Data and Information Set (HEDIS®) was created by the National Committee for Quality Assurance to ensure the care rendered met certain quality expectations which must be tracked in the Electronic Medical Record (EMR) for each patient.
Each of these healthcare drivers, in their own way, have not only driven how we provide care but also how we record and share health information. As a result, neither providers or patients drive the visit.
The computer and insurance documentation requirements now drive the visit.
It controls when you see a patient, how long, and how many you see in any given day. Providers have more and more patients on their panels, and it has become unmanageable because they have more people who need to be seen than there is time in the day. The volume of patients combined with the increased security and documentation requirements have made their task very difficult.
The patient experience through their primary care provider visit has shifted to filling out forms and questionnaires regarding their health. It's more complex than just checking their weight and blood pressure. Now, it is a comprehensive visit driven by insurance carrier requirements which takes longer than it used to. Doctors have to check for depression, assess if the patient is at risk for falling, if they have had their mammogram or colonoscopy, and go through a variety of questions that may not even be why the patient is sitting in front of them in the first place.
And so, we've seen this evolution in primary care that shifted from patient-centered to volume because that is how we were reimbursed for services provided.
But now we realize what we lose in that volume. We see how focusing on volume was a disservice to the patients because we wanted revenue from the visits, but we were losing something. We were losing patient engagement through the necessary documentation and the sheer numbers. The quality of care suffered.
Now quality is coming back to the forefront. We realized it is cheaper to keep people healthy than to treat them when they're sick.
We found value in working with a patient to lower their blood pressure, potentially preventing a costly cardiac event, and subsequently impacting the cost of healthcare. We give the patients education and resources to help them lose weight which can lead to significant health concerns. We conduct Annual Wellness Visits with Medicare patients to identify concerns such as dementia, cancer, or other high risk health concerns.
Primary care is where it starts. Ideally, patients build a trusting relationship with their primary care provider, and that established partnership keeps them healthy for their entire life.
Next week, I will dive into some practical next steps for providers and their teams to work towards a more quality-focused way of doing care. Stay tuned!
